A user’s guide: 20 things to know about the Affordable Care Act

By Carol Ostrom

The Seattle Times (MCT)

Published: Wednesday, Sept. 25 2013 12:00 a.m. MDT

4. Insurers can no longer reject you or charge you more because you have a health condition. Trouble getting coverage because you have a pre-existing condition or a chronic illness is now a thing of the past. The “high-risk pool” insurance plans will dry up.

5. Your kids can be on your policy until they’re 26. Which is pretty much a blessing, because if they got hurt or seriously ill, you’d probably pay their health-care expenses anyway, wouldn’t you?

6. You can’t sign up for insurance coverage all year long. So if you don’t have insurance, it’s not a good idea to think: Oh, I’ll just pay the penalty and wait until I’m sick or injured or rich to sign up. You’ll be able to sign up only during specified open-enrollment periods.

This year, a special six-month period lasts from Oct.1 to the end of March 2014. Later enrollment periods will be shorter.

7. If you’re a mom, you’re the most-trusted adviser to over-26 kids. So you’re the one who needs to explain that, yes, they can pay the penalty and skip insurance. But if they break an arm or a shoulder in a bike crash they could end up with a big honking hospital bill — and a lousy credit rating — that could dog them well into the next phase of their life.

8. There is a new way to compare and sign up for individual insurance. In Washington, the insurance-exchange marketplace will appear Oct. 1 as the Washington Healthplanfinder, a one-stop shopping site that will take care of a lot of messy details for you.

9. The Healthplanfinder will do some whiz-bang stuff behind the curtain. You’ll be able to find out, for example, if your income qualifies you for free or lower-cost insurance.

If you make less than $15,856 ($32,499 for a family of four) you likely will qualify for Medicaid, the federal-state plan that has been greatly expanded.

If you make up to $45,950 ($94,200 for a family of four) you may get a subsidy that will reduce your premiums.

If your income is low enough, you can qualify for a second type of subsidy to help with cost sharing (out-of-pocket costs). It also will link you with various other services, if you qualify.

10. The exchange isn’t the only way. You’ll still be able to buy individual insurance through a broker, or through the insurer the same way you signed up before. Some insurers will offer some “grandfathered” plans left from the good old days.

And there will be other choices, just as there are today.

But there are no subsidies for purchases outside the exchange.

11. If you work for a big, self-insured company, you won’t see many changes. At least not right away. Expect more emphasis on wellness programs, some pressure to select a health savings account (HSA) or health reimbursement arrangement (HRA) plan, and some squeezing when it comes to choice of health networks.

12. Expect new arrangements between insurers and doctors and hospitals. In general, they may lead to better coordination of care, but you may also see fewer choices of doctors, clinics and hospitals.

You may hear about “ACOs” — accountable care organizations. Think of them as health-maintenance organizations “lite.” They are moving away from paying for each health-care service — “fee for service” — toward incentives that reward both insurers and providers for keeping patients healthy.

13. You might want to call way ahead of time to make that doctor’s appointment. If it turns out that more people are insured, there just might be a few more patients in the waiting room.

14. Don’t expect costs to go down soon. If there is anything systematic about our “system” of health care and insurance, some experts argue, it is this: It has kept costs down, such as they are, by keeping sick people out, or limiting their access.